History of Medicine

The epidemic of Athens,430 - 426 BCFrancois P Retief, Louise Cilliers

The Athenian epidemic of 430 - 426 BC, at the outbreak of

the Peloponnesian War, caused the death of the great

statesman, Pericles, decimated the population and

contributed significantly to the decline and fall of classical

Greece. In his remarkable documentation of the epidemic,

Thucydides (who survived the disease) not only left us a

clear clinical picture of the pestilence but also identified its

infectious nature and the fact that it conferred at least

partial immunity on survivors. As confirmed by a large

number of scholars who studied the subject, Thucydides'

description does not accurately fit any existing disease,

but we suggest that analysis of the signs and symptoms,

considered in conjunction with significant epidemiological

evidence, narrows down the many possibilities to

epidemic typhus, plague, arboviral disease (e.g. Rift Valley

fever) and smallpox. Typhus and smallpox fit best, but we

favour the latter for reasons given. Unless further primary

sources of information become available (and this seems

most unlikely), productive speculation as to the cause of

Thucydides' epidemic has probably reached the end of

the road.

S Atr Med J 1998; 88: 50-53.

In the year 430 BC, a few months after the outbreak of thePeloponnesian War, a devastating epidemic struck Athensand surrounding Attica, killing at least one-quarter of thepopulation.'" It is probably the best documented epidemicof ancient times and contributed significantly towards thefall of classical Greece. It heralded the end of the 'Age ofPericles' when the great statesman died during the epidemicin 429 BC, although Athens was still to enrich Westerncivilisation through subsequent contributions by Sophocles,Euripides, Plato, Aristotle and others.

In his The Peloponnesian War, book 2 (chapters 47 - 52),Thucydides gives a detailed description of the epidemic,'and over the past 500 years scholars have attempted toidentify the disease. This has led to more than 200publications and even a panel discussion at the annualmeeting of the American Philological Association in 1984.4

No final consensus has been reached, but excellentreviews have been published}" Instead of attempting to

PO Box 29521, Danhof, 9310 Bloemfontein

Francois P Retief, MD, 0 Phil, FRCP IEd,n)

Department of Latin, University of the Orange Free State,Bloemfontein

Louise Cilliers. o.a Lm et Phil. 0 lilt et Phd

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cover the whole field, this paper will provide a generaloverview and a discussion of the most likely diagnosticoptions.

The authorThucydides' classic description is our only primary source ofreference, although a number of subsequent writers andhistorians added to the story. For instance, Diodorus Siculus(1 st century BC)! relying on the informant, Ephoros, givesadditional information which often clashes with Thucydides'description; its veracity, however, is open to serious doubt.Similarly, Lucretius (1 st century BC)9.,o and Plutarch (1 stcentury AD)9 wrote from hearsay at a much later date, whileGalen (2nd century AD), with no further information at hisdisposal, tended to be critical of Thucydides, comparing himunfavourably with Hippocrates." Aetius (390 - 435 AD) andothers record the legend (certainly apocryphal) thatHippocrates aborted the epidemic by lighting a hugebonfire."

A soldier and noted classical historian, Thucydides (460 ­400 BC) survived an attack of the Athenian disease.' Hisdescription of the epidemic is among the great medicalcontributions of ancient times. He wished to leave toposterity an accurate picture of the epidemic, so that itcould be recognised if it ever recurred. Page' points out thatalthough Thucydides was not medically trained he wascertainly familiar with the writings of the Hippocratic school- and it should be kept in mind that the total volume ofliterature available to an educated 5th-century Athenianwould have contained a significant medical component.'2Characteristic of the Hippocratic tradition, Thucydidesdescribed what he saw, concentrating on prognosis ratherthan diagnosis, classification or speculation about the causeof disease.'·13 He said:

Each individual, whether doctor or layman, is free to relate hispersonal opinion about the origin of the plague, and thecause of this unprecedented disturbance, if he can find anypowerful enough to account for it. For my part, I shalldescribe it as it was, and provide evidence in the light ofwhich the student may have some knowledge in advance,and so have the best chance of recognizing it if it should everrecur.'

Hippocrates was a contemporary of Thucydides, but thereis no mention of this epidemic in the Hippocratic writings.Speculation that Thucydides, the historian, might havefabricated the epidemic in order to augment the impact ofthe disastrous events,"" has been thoroughly discredited.3

However, as a lay historian, he was describing a momentousmedical saga to a lay public, and it is not impossible that hispoetic style might have had some influence on the factualcontent of his story.'.3·'2,,4

Athens and the PeloponnesianWar (431 - 404 BC)At the outbreak of the war with her Peloponnesianneighbours (mainly Sparta), greater Athens had an area of

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approximately 4 square miles, consisting of the harbour areaof Piraeus connected to the mother city by Pericles' famouslong walls"·6According to Gomme' the enclave held 155 000inhabitants (60 000 citizens, 25 000 metics, 70 000 slaves)before the war, housed in 10 000 dwellings. The totalpopulation of Attica was close on 400 000, fewer than halfof whom were slaves, and indications are that it was agenerally healthy community.9

In view of Athenian naval supremacy, excellentfortifications and good harbour facilities, Pericles decided toaccept a siege without engaging the Spartans on land. Thetotal population of Attica was brought into Athens, causing apopulation density of approximately 100 000 inhabitants persquare mile with severe overcrowding (and very poorhousing) in the long walls area, in particular""'·

The siege commenced early in the summer of 430 BC andinitially lasted a year, during which time the Spartans laidwaste the Attican countryside. Periodic sieges followed, butduring the summer of 429 and the winter of 427/426 BCthere was no invasion. In all, the war lasted 27 years beforeAthens capitulated in 404 BC. The epidemic of 430 - 426 BCundoubtedly had a severely demoralising effect and causedthe death of the great Pericles, but Athens recoveredsufficiently to sustain the war effort energetically, to counter­attack at sea and even to launch the unsuccessful offenceagainst Syracuse in 414 BC. This disaster and the virtualdestruction of their fleet in 405 BC were probably the maincauses of ultimate defeat."··

The epidemicAs pointed out by Page' any meaningful attempt atdetermining the cause of the epidemic depends on theaccuracy of the translation of Thucydides' text. Not onlymust the original Greek medical terms be accuratelytranslated, but their meaning in the fifth century BC must bedetermined. The following translation of relevant passages iswidely accepted:""

It was generally agreed that in respect of other ailments noseason had ever been so healthy. Previous diseases all turnedoff into the plague; and the rest of the people were attackedwithout eXciting cause, and without warning, in perfect health.

It began with violent sensations of heat in the head, andredness and burning in the eyes; internally, the throat andtongue were blood-red from the start, emitting an abnormal andmalodorous breath. These symptoms developed into sneezingand hoarseness, and before long the trouble descended into thechest, attended by violent coughing. Whenever it settled in theheart: it upset it, and evacuations of bile ensued, of every kindfor which the doctors have a name; these also together withgreat distress. Most patients suffered an attack of emptyretching, inducing violent convulsions, in some cases soon afterthe abatement of the preVious symptoms, in others much later.

The body was neither unduly hot externally to the touch, noryellowish in colour, but flushed and livid, with an efflorescenceof small blisters and sores. Internally the heat was so intensethat the victims could not endure the laying-on of even thelightest wraps and linens; indeed nothing would suffice but theymust go naked, and a plunge into cold water would give thegreatest relief. Many who were left unattended actually did this,

• Some scholars interpret kardia as stomach.

jumping into wells, so unquenchable was the thirst whichpossessed them; but it was all the same, whether they drankmuch or little. The victims were attacked throughout by inabilityto rest and by sleeplessness.

Throughout the height of the disease the body would notwaste away but would hold out against the distress beyond allexpectation. The majority succumbed to the internal heat beforetheir strength was entirely exhausted, on the seventh or ninthday, or else, if they survived, the plague would descend to thebowels, where severe lesions would form, together with anattack of uniformly fluid diarrhoea which in most cases ended indeath through exhaustion.

Thus the malady which first settled in the head, passedthrough the whole body, starting at the top. And if the patientrecovered from the worst effects, symptoms appeared in theform of a seizure of the extremities: the privy parts and the tipsof the fingers and toes were attacked, and many survived withthe loss of these, others with the loss of their eyes. Some rosefrom their beds with a total and immediate loss of memory,unable to recall their own names or to recognize their next ofkin.

For the peculiar characteristics of the disorder could not bedescribed in words; and while in general it attacked eachsufferer with a violence greater than human nature can bear, inthe following point especially it showed plainly that it wassomething different from the diseases bred among us. All thebirds and beasts that feed on human flesh, though manycorpses lay unburied, either did not approach these, or perishedafter tasting them. As a proof of this there was a markeddisappearance of such birds, and they were not seen eitherengaged in this way or otherwise; while the dogs, through theirdwelling with men, gave a better opportunity of observing theeffect on animals.

Thucydides gives further information relevant to theepidemic:,,15

1. The disease apparently originated in Ethiopia andpassed through Egypt, Libya and the greater part of thePersian Empire before reaching Lemnos and Athens viaPiraeus. Elsewhere in Attica only the more denselypopulated areas were affected and then less severely thanAthens. The Peloponnese was spared, and Spartan soldiersbesieging Athens were not infected.

2. Thucydides noted that all segments of the populationwere affected indiscriminately, and that doctors (who knewno name or cure for the disease) were particularly hard hit.Depression was a prominent symptom. Overcrowding wasblamed as an aggravating factor, but it must be noted thatthe epidemic recurred in the winter of 427/426 BC whenAthens was not besieged" Thucydides clearly recognisedthe infectious nature of the disease and that patients whosurvived the illness were immune to further attacks ordeveloped only mild recurrences,, 7

3. The mortality rate of the disease among Atheniansoldiers (hoplites) in Attica was 33%, and among soldiers inan expeditionary force to Potidea it was 26%",·,'6 QuotingDiodorus Siculus, Bellemore et al. recently claimed that themortality among commoners in the city was as low as2 - 5%5 but, as stated elsewhere, the validity of Diodorus'information is questionable. Gomme6 calculated that thepopulation of Attica decreased by 31 % between 431 and425 BC. According to Morens and Littman4 the epidemic'soverall attack rate would have varied between 25% and100% with a case fatality rate of approximately 25% .

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4. Thucydides accentuates the horrors of the epidemic byhis graphic description of resultant moral and social declinein the community under siege. Initially prayers were offered,and the gods and the oracles were consulted, but when allthese activities proved futile, a widespread breakdown oftraditional morality and restraints of law developed. TheGreeks considered burial rites to be sacred and binding, buteven these were abandoned and men were observed toleave corpses lying in the open or to toss them on top ofalready burning funeral pyres. Horstmanshoff17 feels that thedegree of social decline might have been overstated byThucydides and that much of it was precipitated by theteachings of sophists and opponents of Pericles, whoclaimed that his policy of overcrowding Athens had causedthe epidemic.

5. The epidemic continued uninterrupted for at least 2years (summer of 430 BC to summer or autumn of 428 BC),and then apparently died down but reappeared explosivelyin the winter of 427/426 BC. It was therefore not season­bound.

DiscussionThucydides' description clearly does not accurately matchany epidemic disease known today, but it does resemblesome. Assuming that he recorded a valid description of anactual event, one could speculate that: (I) the Athenianepidemic was a disease which no longer exists; althoughmedical history does record mysterious illnesses whichapparently became extinct, like the English 'SweatingSickness' (1485 - 1552) and 'Suette des Picards' (1718 ­1870), this is a rare occurrence;'·13 or (iI) the disease stillexists but became modified over 25 centuries; this is adistinct possibility which would complicate present-daydiagnosis; experience has shown that diseases usuallybecome less virulent in time;7 or (iil) the disease hasremained virtually unchanged - the descriptions of mumpsand malaria in the Hippocratic corpus, for instance, are stillclearly recognisable today.'· A further complication could bethe simultaneous occurrence of more than one disease.'

At least 30 different disease entities have so far beensuggested as possible causes of the Athenian epidemic.'The majority of authors focused on finding a fit for the signsand symptoms described by Thucydides. These can besummarised as follows: Acute onset of severe pyrexialillness with initial inflammation of eyes and respiratory tract,followed by upper gastro-intestinal disturbance, a vesicularskin rash with open sores (there is controversy over theprecise meaning of the Greek word phlyktainai, but majorityopinion favours a skin rash with an element of blistering orulceration) and death on the 7th (or 9th) day. Survivors ofthis stage developed watery diarrhoea and dehydration,which usually proved fatal. Those who recovered oftendeveloped peripheral gangrene of fingers, toes and genitals,loss of vision and total amnesia.

More recently scholars have stressed the importance ofan epidemiological approach,' pointing out that Thucydidesshould be credited for his pioneering recognition of theinfectious nature of the disease and the fact that it conferredimmunity against further fatal attacks. The importantepidemiological aspects are as follows:

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It was a previously unknown disease with an explosiveonset (short incubation period), affecting all populationgroups, originating in Africa (Ethiopia and Egypt) andspreading rapidly to the Middle East and Greece (Athens viaPiraeus, thus probably ship-borne); it was not seasonal butits spread was apparently dependent on population density;it waxed and waned but lasted approximately 4 years, had amortality rate of 25% or more, and conferred at least partialimmunity.

The possible transmission of disease to birds and animalsof prey could suggest enzootic or epizootic involvement, butmost authorities consider Thucydides' comments in thisregard too vague for firm conclusions.'''·1. However, hisdefinite statement that animals who fed on corpses diedafterwards remains an unsolved issue.

Descriptions of a severe epidemic in Rome (433/432 BC)'and in the Persia of Artaxerxes (for which Hippocrates wasconsulted)" provide corollary evidence of a pandemic in theMediterranean basin.

Using modern epidemiological analysis, Morens andLittman' came to the conclusion that the Athenian epidemicwas consistent with either an infectious agent associatedwith an animal or insect reservoir, or respiratory transmissionwith a 'reservoir-like' mechanism ensuring persistent re­infection. This eliminates the vast majority of suggesteddisease entities, and almost all zoonotic diseases proposed,as the latter only affect humans accidentally ('dead end'),e.g. glanders, leptospirosis, rabies and tUlaraemia. Onclinical grounds, anthrax is a possibility, but large-scaleanthrax epidemics are not known to occur and norecognised reservoir is identifiable, as Athenian sheep andcattle had been dispatched to Euboea. According to Morensand Littman' only epidemic typhus, plague, arboviral diseaseand smallpox would pass a screening procedure based onepidemiology. These diseases are also consistent withThucydides' clinical picture of the epidemic, although all fourpresent significant diagnostic difficulties.

1. Epidemic typhus. This louse-borne disease which,through the ages, has accompanied wars and famine, is theonly favoured disease which typically causes gangrene ofthe extremities, as well as blindness and amnesia.20

However, its characteristic skin rash is not bullous. Althoughlice occurred abundantly in ancient Greece and someauthors claim that Hippocrates recognised typhus,20 there islittle evidence that the disease existed much before Cardandescribed it in the 16th century!'

2. Plague. This flea-borne disease with the rat as usualanimal host was not endemic in classical Greece, butPasteurella pestis almost certainly originated in ancient timesin India and/or Africa in association with colonies of ground­burrowing rodents." The 'black rats' of Indian origin becameits major vehicle of spread" There is some evidence thatrats were uncommon in ancient Greece, and the Greeklanguage had no word for rat (unless it is included undermus, the generally accepted word for 'mouse')." Theepidemic of Constantinople in 542 AD probably representsthe first recorded plague epidemic - a disease which latercreated havoc as the 'Black Death' in medieval Europe".22Plague classically manifests itself in either bubonic orsepticaemic forms, but neither produces a bullous skin rashand Thucydides would certainly have commented on thestriking and pathognomonic buboes of bubonic plague, hadthey been present.

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3. Arboviral disease. Although Morens and Chu havesuggested that the 4th and 5th Pharaonic plagues of Exodus8 and 9, could have been Rift Valley fever;' this disease isgenerally considered to be of recent origin, first described inKenyan sheep (1912). Human infection was recorded byGear in 1951; originally considered a mild disease, lateroutbreaks in South Africa (1976) and Egypt (1977) carriedconsiderable mortality:' Epidemiologically acceptable andcharacteristically affecting both man and animal, the clinicalpicture of Rift Valley fever (as the prototype of arboviraldisease) resembles Thucydides' disease only vaguely. Otherarboviral diseases like yellow fever and dengue have beenconsidered, but are even less likely candidates.'

4. Smallpox. Sallares9claims that the Egyptian Eberspapyrus (2nd millennium BC) may contain a description ofsmallpox, and that there is some evidence that Ramses Vdied of it in 1157 BC. Uttman and Littman2 postulate thatsmallpox has been endemic in Africa since ancient times. Itsdecisive role in the 'Elephant War' (7th century AD), andRhazes' classic description in the 10th century'9 establishedsmallpox as an epidemic disease. The clinical manifestationsof smallpox might well have undergone significant changeover the past two millennia, but present-day smallpox stillcomes closest to the disease described by Thucydides. Itsepidemiological features fit the Athenian disease, althoughmore rapid extinction might have been expected" However,Morens and Uttman' point out that persistence of theepidemic over 4 years could be explained on the basis ofreinfection of a closed 'virgin-soil' community (smallpoxepidemics need a critical mass of 200 000 persons) bysporadic re-introduction to Athens of inhabitants from lessdensely populated areas of Attica, during lulls in the war.Peripheral gangrene is not characteristic of small pox per se,but severe systemic infection associated with diarrhoea andcirCUlatory collapse late in the disease might have caused it.Some scholars consider the lack of mention of typical poxmarks as significant evidence against this disease, butUttman and Littman2 point out that Thucydides wasdescribing the symptoms of the active disease while pockmarks are later sequelae. It is also interesting to note that inhis classic description of smallpox, Rhazes mentioned pockmarks in only one of his patients. A very strong point infavour of smallpox is the bullous rash so clearly describedby Thucydides - a hallmark of this disease.

5. Other diseases considered. Langmuir et al."postulated that the Athenian epidemic was not a singledisease, but a combination of influenza and toxin-producingstaphylococcal infection (the 'Thucydides syndrome'). Froman epidemiological point of view, this particular hypothesispresents many problems but other scholars have alsosuggested multiple pathology,2.7

,25 and this remains a distinctpossibility, and very difficult to exclude.'

Other diseases considered include measles, ',3.26 which maycause devastating epidemics in 'virgin-soil' communities (ashistory has shown) but presents a different clinical pictureand needs a critical population mass of at least 500 000 tocause an epidemic." From an epidemiological point of view,malaria is incompatible with the explosive epidemicdescribed by Thucydides" Typhoid is water-borne andAthens did not have the centralised water supply systemessential for an epidemic of this disease.. Similarly, choleraand dysentery can be excluded on both clinical andepidemiological grounds.'

There have also been interesting suggestions that theepidemic might have been of a non-infectious nature.Kobert25 and Salway and Dell27 thought that ergotism couldhave been at least partially responsible for the epidemic,while Bellemore et al. 5 present a well-motivated case foralimentary foxic aleukia caused by a mycotoxin'scontamination of the Athenians' grain supply imported fromthe Black Sea area. However, the widespread nature of thepandemic as well as strong evidence of an infectiousaetiology count heavily against this interesting hypothesis"

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452.1B. Siegel RE. Epidemic and infectious disease at the time of Hippocrates. Gesnerus

1960; 17: 77-98.19. Zinsser H. Rats, Uce and History. Boston: Uttle, Brown, 1935.20. McArthur WP. The Athenian plague: a medical note. Classical Quarterly 1954; 48:

171-174.21. Major RH. Classic Descriptions of Disease. Springfield, Ill.: Charles C Thomas.

1959.22. McNeill WHo Plagues and Peoples. New York: Anchor Pres., 1976.23. Morens OM, Chu MC. The plague of Athens. N Engl J Med 1986; 314: 855.24. Laughlin LW. Meegan JM, Strausbaugh W, Morens OM, Walten RH. Epidemic Rift

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25. Kobert R. Ober die Pest des Thucydides. Janus 1899; 4: 240-251.26. Shrewsbury JFD. The plague of Athens. Bull Hist Med 1950; 24: 1-25.27. Salway P, Dell W. Plague at Athens. Greece and Rome 1955; 2: 62-70.

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